personal dental assessment

Medical History FormPersonal Dental Assessment

Please tick and provide details, in the space provided: Yes No
Welcome to Dental Sense. For us to ensure
Details of Medical Condition, Current / Pass Medical Treatment and Medications taken and
appropriate dental care, we kindly ask you to
Are you in good General Health?Medication currently takingHEART- damaged or replaced heart valves, angina,
information that you provide is held within
strictest confidence at the practice.CHEST- asthma, shortness of breath?Surname: ……………………….BLOOD PRESSURE (High or Low?) please stateBLOOD - Anaemia, prolonged bleeding?First name(s):……….…………. LIVER / KIDNEY DISEASE?NERVOUS SYSTEM - Epilepsy?Title.DoB:……/……/.…JOINTS & BONES - Arthritis, Artificial joints?Address:………………………….SKIN - Eczema?INFECTIOUS AGENTS – HIV / AIDS, Hepatitis, TB?
………………………….………….ALLERGIES to any drugs or material? e.g. Penicillin, Latex?
……………………………….……
Do you have DIABETES?Do you SMOKE?Post Code: ………………………
Have you taken Steroid medicine in the past 2yrs?Are you taking medicines to thin your blood? e.g. Tel 1(h)….…….….…………….Warfarin, AspirinAre you taking Bisphosphonate medication? e.g. Tel 2 (w/m)….…….………….
FosamaxAny other Serious illness’s or Surgery?Occupation: ………….…………. Female patients: Are you Pregnant?e-mail: …………………………….
Are you taking the Oral Contraceptive Pill?
Date of last Dental Visit:
…………………….……………….
Would you like your teeth to look whiter or brighter?
NHS Number:
…………………………………….
Do you have any teeth that are unsightly or crooked?
Do you have Dental Insurance:
Are you concerned about any old crowns that do not match?
Do you have any missing teeth that you would like to replace?
Would you prefer tooth coloured fil ings to replace any silver ones?
Do you consider yourself a nervous patient?
How did you hear about us?
Would you be interested in comprehsive dental care?
What (if anything) would you like to change about your teeth? .
. ………………………………………………………………………….
……………………………………………………….
I have completed this Questionnaire to the best of my knowledge, and understand that failure to disclose all information may
Medical Doctor Name & Address
place ME at undue medical risk. I also give my permission for the practice to use the above contact details to call or send me appointment and check-up reminders.
Emergency Contact Name & Tel.378 Malden Road, Worcester Park, Surrey KT4 7NL tel:- 020 8337 349641 Windsor Road, Chobham, Surrey GU24 8LD tel:- 01276 855 994Website:email: [email protected]Medical History Form
Patient Signature ____________________________
378 Malden Road, Worcester Park, Surrey KT4 7NL tel:- 020 8337 349641 Windsor Road, Chobham, Surrey GU24 8LD tel:- 01276 855 994Website:email: [email protected]

Differentiation of Emboli Background: The difficulty of distinguishing solid from air emboli using transcranial Doppler has limited its use in situations where both types of emboli can occur, such as in mechanical heart valve patients. Particulate microemboli are thought to be the most damaging. Literature: Analysis of index modulation in microembolic Doppler signals par